Behavioral therapy across the spectrum.

Numerous effective behavioral therapies have been developed that can bring the treatment to the patient rather than bringing the patient to treatment. These behavioral therapy techniques, which can provide effective treatment across the spectrum of severity of alcohol abuse disorders, include facilitated self-change, individual therapies, couples and family approaches, and contingency management. New methods of delivery and successful adjuncts to existing behavioral treatments also have been introduced, including computerized cognitive–behavioral treatments, Web-based guided self-change, and mindfulness-based approaches. Although a wide variety of behavioral approaches have been shown to have good efficacy, choosing the treatment most appropriate for a given patient remains a challenge.

S ince the mid1980s and 1990s, couples and family treatments, facilitated techniques designed to facilitate healthy behavioral treatment of alcohol selfchange approaches, and aversion behavior change. Coping skills training, abuse and dependence (i.e., alcohol therapy. Many other alcohol treatments cognitive behavioral treatment, brief use disorders [AUDs]) has advanced also incorporate behavioral principles. behavioral interventions, and relapse steadily. This article introduces different For example, 12step groups (e.g., prevention also introduce concepts from types of behavioral treatment, summa Alcoholics Anonymous) often rely on cognitive therapy and social learning rizes the evidence for their efficacy, and positive reinforcement (e.g., by recog theory, primarily the identification describes alternative methods of delivery nizing abstinence anniversaries) and of cognitions related to alcohol use and adjuncts to existing treatments that behavioral modeling (e.g., by having and situations in which maintaining abstinence might be challenged. For might appeal to some patients. In addi a sponsor). Motivational interviewing example, the cognitive concept of tion, the article discusses the importance (see Miller and Rose 2009) also often of moving beyond a focus on compar relies on behavioral principles (e.g., selfefficacy, or belief in one's ability to abstain from alcohol, plays a promi ing the effectiveness of existing active reinforcement, modeling) within the nent role in both cognitive-behavioral behavioral treatments and toward a treatment session. This review high treatments and relapse prevention. research agenda that considers more lights those interventions that are Likewise, an individual's expectations thoughtfully how people change as well rooted in behavior therapy (see table).
regarding the effects of alcohol (i.e., as the mechanisms of change during All of these treatments can be delivered expectancies) often are identified the course of behavioral treatments.
in individual sessions or group formats, and challenged during the course of and many of them have been adapted cognitive-behavioral interventions. to be delivered in a variety of treatment Coping skills training and relapse   Behavioral Therapy Across the Spectrum highrisk situations for drinking and then building a repertoire of coping skills to help patients approach risky situations without using alcohol. Brief interventions, such as brief physician advice (Fleming et al. 2000) and the Brief Alcohol Screening and Intervention for College Students (BASICS) approach (Dimeff et al. 1999), also utilize many cognitive-behavioral tools; however, in these cases, treatment occurs over a short period of time (often an hour or less). The effectiveness of these approaches has been demonstrated in numerous studies. For example, Fleming and colleagues (2000) found that brief physician advice, delivered across two physician visits and two followup phone calls, resulted in a significant reduction in alcohol use and binge drinking episodes for up to 4 years following the intervention. More recently, a study found that brief interventions were equally effective for alcohol dependent and nondependent participants (Guth et al. 2008).

Contingency Management Approaches.
Contingency management approaches rely more exclusively on the principles of operant conditioning-that is, they use reinforcing and punishing consequences to maintain positive behavior change. Contingency man agement approaches, which often are used as an adjunct to another treat ment, share three central components: • Monitoring the individual carefully (e.g., using urinalysis or blood tests) so that alcohol use is identified; • Providing tangible positive rewards (such as vouchers that can be exchanged for retail goods or cash) for a desired behavior (e.g., abstinence from alcohol); and • Withholding rewards (e.g., vouchers) or implementing other negative consequences (e.g., providing negative reports to interested other parties, such as family members or parole officers) when alcohol use is identified.
Cognitive therapy typically is not part of a contingency management treatment; however, contingency management can lead to increased selfefficacy for abstinence (Litt et al. 2009), potentially by providing indi viduals with the experience of being abstinent from alcohol (Witkiewitz and Marlatt 2008).

Behavioral Couples, Marital, and
Family Therapy. These approaches incorporate a thorough assessment of drinking behaviors and an analysis of relationship factors that may influ ence these behaviors, including com munication, conflicts, and problem solving. Both behavioral couples treatment (McCrady and Epstein 1995) and marital family therapy (O'Farrell et al. 1993) incorporate several behavioral techniques designed to reduce drinking and drinking related problems as well as increase caring behaviors, enhance communi cation, and improve relationship functioning. Recent studies have found that both behavioral couples therapy and behavioral family therapy are related to better outcomes following treatment than behavioral individual therapies (see McCrady et al. 2009;O'Farrell et al. 2010). Skills training, contingency management, and behav ioral contracting often are primary components of these treatments. Facilitated SelfChange. The majority of people with AUDs do not seek treatment, and most of them are able to quit drinking or maintain moderate drinking without receiving formal treatment. Thus, most people quit drinking on their own. In light of these findings, several treatments have been developed that aim to facilitate selfchange. For example, behavioral selfcontrol training (Miller and Munoz 1982) and guided selfchange (Sobell and Sobell 1993; also see Klingemann and Sobell 2007) are two programs that have received consider able empirical support for reducing alcohol use and alcoholrelated prob lems. For most facilitated selfchange programs, primary treatment goals include goal setting, selfmonitoring of drinking behavior, analysis of drinking situations, and learning alternate coping skills. Many of these treatment approaches are delivered via selfhelp workbooks or computer programs, are Internet based (e.g., Smart Recovery), or are administered via mailed interventions. Facilitated selfchange approaches also can be therapist directed in individual or group formats.
Aversion Therapy. Aversion therapy relies almost exclusively on behavioral principles of conditioning. The goal is to help patients reduce or eliminate their alcohol use behavior by condi tioning a negative response (e.g., an electric shock or nausea) to cues that were previously associated with drink ing. In some cases, such as treatment with the drug disulfiram (Antabuse ® ), patients will have a highly unpleasant physical reaction if they consume even small amounts of alcohol. 1 Imagining unpleasant scenes combined with imagery of drinking (i.e., covert sen sitization) also has been used as a form of aversion therapy (Rimmele et al. 1995). In general, however, aversion therapies are not widely used today.

Efficacy of Behavioral Treatments
Several reviews and metaanalyses of the research literature have determined that behavioral treatments-including brief intervention, marital and family therapy, behavioral couples therapy, relapse prevention, and other cognitivebehavioral treatments as well as com munity reinforcement and contingency management approaches-are among the most effective treatments for AUDs (see Finney and Monahan 1996;Miller and Wilbourne 2002). Specifically, study findings included the following: • Recent metaanalyses of cognitivebehavioral treatments (Magill and Ray 2009) and contingency man agement approaches (Prendergast et al. 2006) have concluded that effect sizes for either treatment approach range from small to medium, depending on the comparison group (e.g., active treatment or control group), definition of outcome (e.g., abstinence or reduced alcohol prob lems), and followup time (e.g., 6 vs. 12 months after treatment).
• A metaanalysis of behavioral couples, marital, and family therapy (Powers et al. 2008) found that for married or cohabiting patients, these approaches yielded medium to large effects and better outcomes than individualbased treatments.
• A metaanalysis of 17 studies evalu ating behavioral selfcontrol training (BSCT) indicated that this approach produced moderately strong effects in comparison to no intervention and smaller effects in comparison to abstinenceoriented comparison treatments (Walters et al. 2000).
To more accurately compare the effectiveness of treatments across dif ferent studies using different study designs, Miller and Wilbourne (2002) created a cumulative evidence score that takes into account the treatment effects as well as the methodological strengths and weaknesses of the studies. This score was used to ascertain the effectiveness of different treatments based on 361 controlled studies. Of the psychosocial interventions analyzed, brief interventions had the highest cumulative evidence, yielding signifi cant reductions in drinking across most studies, even in non-treatment seeking populations. Behavioral interventions, including community reinforcement, behavioral contract ing, behavioral marital therapy, skills training, chemical aversion therapy, covert sensitization, and selfcontrol training, also ranked in the top 20 of all treatment modalities (Miller and Wilbourne 2002). In addition, relapse prevention, contingency man agement, Drinker's Checkup, and behavioral couples' therapy have been identified as effective by the Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of EvidenceBased Programs and Practices (see www.nrepp.samhsa. gov).
However, although many behav ioral treatments have been found to be effective, a recent metaanalysis has questioned whether these various behavioral treatments result in signifi cantly different outcomes compared with other bona fide psychological treatments 2 for AUDs (Imel et al. 2008). In a review of 30 studies that had compared at least two bona fide psychotherapies, these investigators found that net effect sizes across treatments were not significantly different from zero, suggesting that all treatments produced similar effects. Looking at individual studies, the investigators also found that authors' allegiance to a particular treatment explained a significant portion of the variability between different treatment outcomes. In addition to these findings, there is scant evidence to support the efficacy of these behavioral treatments with minority groups and among patients with comorbid mental health disorders, and future metaanalyses are desper ately needed to determine which treatments work best for these groups.

Adaptations of Existing Behavioral Treatments
Alcoholism treatment can be provided in a wide range of settings. Several outcome studies have concluded that inpatient (i.e., residential) treatment offers no advantages over outpatient treatment of alcohol dependence. Also, research on alcohol screening and intervention in primarycare facilities (Fleming et al. 2000) and emergency 1 Thus, disulfiram is not technically a pharmacological treatment for alcohol dependence because it only has aversive conditioning properties and does not directly influence alcohol consumption. In contrast, newer medications for alcohol dependence, including naltrexone and acamprosate, have very different mechanisms of action and can reduce alcohol consumption with or without con current behavioral treatment (COMBINE Study Research Group 2006). departments or trauma centers (Gentilello et al. 1995;Monti et al. 2007) indi cates that these alternative treatment settings might be essential for helping people who otherwise would have not sought treatment. Accordingly, those treatment approaches that can be adapted to different treatment settings are particularly useful. Most of the behavioral approaches described above can be adapted for multiple settings (e.g., inpatient or outpatient treatment, community centers, schools, primary care clinics, or emergency rooms) and delivery methods (e.g., phone, Internet, computerbased, postal mail), and a growing body of research evidence supports the adaptability of behavioral interventions. The adaptation of these approaches to different delivery methods, in particular, has great promise to change the face of treatment for AUDs. As discussed in more detail in the article by Gustafson and colleagues (pp. 327-337 in this issue), computer and Web based approaches are likely to greatly expand the availability of evidence based behavioral treatment strategies. For example, an approach called ComputerBased Training in CBT (CBT4CBT) can predict greater treat ment engagement and decreased drug use compared with usual treatment (Carroll et al. 2008). Similarly, the Drinker's Checkup, a computerbased brief intervention, can reduce the quantity and frequency of drinking by 50 percent, with reductions sustained through 12 months following the inter vention (Hester et al. 2005). Finally, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recently launched a selfchange Web site and booklet called Rethinking Drinking (http:// rethinkingdrinking.niaaa.nih.gov/) that provides interactive feedback and tools for helping people cut back on their drinking. Rethinking Drinking is freely available and has the ability to reach millions of people who might be think ing about changing their drinking behavior on their own.
In another adaptation of existing treatments, recent research indicates the potential value of adding mindfulness training to existing behavioral treat ments for AUDs. Relapse prevention, which best can be characterized as a cognitive-behavioral approach focusing on coping skills training and identifi cation of highrisk situations for relapse, has been expanded to incorporate 8 weeks of group training in mindfulness meditation (Bowen et al., in press). The results suggest significant reduc tions in substance use, including alcohol use and polysubstance use, and craving for substances in the first four months following the interven tion (Bowen et al. 2009).

Understanding How People Change
The majority of metaanalyses and controlled treatment trials have con cluded that most active treatments are equally effective; therefore, it might be more important to focus on defining exactly what treatment components are responsible for this effectiveness. For example, Moos (2007) described four related theories that help explain the active ingredients that are common to most effective treatments, drawing upon social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory to explain common components of effective treatment. According to this analysis, important components included the following: • Social support; • Structure and goal direction; • Provision of rewards and rewarding of activities; • Normative models for successful abstinence; • Enhancement of selfefficacy; and • Teaching of coping skills.
A focus on such empirically supported treatment processes, rather than on different treatment modalities, might provide an opportunity for a more general treatment of AUDs that is linked explicitly to the core processes which instigate and maintain prob lematic drinking patterns.
Those in the alcohol research field have learned over the years that many people change between making the decision to enter treatment or an initial evaluation and actually starting the first treatment session. Consistent with this observation, the provision of specific treatments targeted to address certain individual characteristics determined at pretreatment evaluation has not led to substantial improve ments in treatment outcomes (Project MATCH Research Group 1998). For example, recent analyses of data from the COMBINE Study (COMBINE Study Research Group 2006) 3 indi cated that craving scores decreased significantly between the baseline assessment and the first treatment session (Witkiewitz 2009). Likewise, people with lower levels of craving at baseline did not especially benefit from receiving a specialized treatment session designed to impact craving. Thus, identifying a specific treatment for a certain person (e.g., motivation enhancement therapy for a person with low motivation) may be less use ful than identifying those treatment elements and settings that are most appropriate for a given patient. For example, a patient with no social support system potentially might receive greater benefit from a behav ioral treatment that provided social support or skills for increasing social support for abstinence. Conversely, a person who does not have much time to attend treatment sessions might benefit more from a Web based intervention. And people who are concerned about the implications of receiving formal treatment might be best suited by selfchange methods. Thus, it is important for treatment professionals, concerned family members, and patients who want to change their drinking behavior to consider "what will work best for me?" rather than "what treatment works best?" For researchers it is 3 The COMBINE Study was a multisite randomized clinical trial designed to test the effectiveness of pharmacotherapy with or without combined behavioral intervention in the treatment of alcohol dependence.
imperative to devote more attention to evaluating what treatment processes, settings, and delivery methods work best for which patient and how people change their drinking behavior over time.
It also is critical to note that many studies consistently find reductions in alcohol use among control groups who do not receive behavioral treat ments (e.g., Weiss et al. 2008 ) and among people who do not seek for mal treatment (Sobell et al. 2000;Tucker et al. 2004), and it would be useful to understand the mechanisms contributing to these changes. Further more, few treatment studies to date have examined longterm outcomes and often do not report on morbidity, mortality, or costs of persistent alcohol use following treatment.

Conclusions
As the studies reviewed here indicate, a wide array of behavioral treatments for AUDs produce significant reductions in alcohol use and alcoholrelated problems. People who seek to reduce their alcohol use or quit drinking now are presented with a plethora of options and opportunities for changing their drinking behavior without needing to check in for a 28day inpatient hospi talization, attend Alcoholics Anonymous meetings on a daily basis, or commit to an abstinence goal. The behavioral approaches described in this article share many treatment processes and are generally based on the same underlying theories of behavior. Therefore, investi gations focusing on selecting those treatment processes, settings, and delivery methods that most suit the specific needs of a given patient are a fruitful area of future inquiry. ■